8-year-old girl with a history of eating disorder, (height 1.29 m, 50th centile, weight 17.8 kg, 0.4th centile). Admitted for nasogastric feeding/psychiatry input. New right knee pain and difficulty walking. Iron deficiency anaemia on bloods. Pathological fracture/inflammatory changes needed exclusion. Later bleeding gums were demonstrated. Ascorbic acid/anti-psychotic medication was prescribed. Knee pain disappeared after 3 days with normal mobility.
Initial knee X-ray was unremarkable.
Subsequent right knee MRI showed marrow oedema around the proximal tibia / fibula metaphysis, reduced tibia growth plate thickness, significant periosteal thickening / reaction around the fibula and a joint effusion. Further significant soft tissue oedema around the focal bony changes was present mainly around the proximal fibula. The distal femoral growth plate was normal.
A repeat MRI 2 weeks later after ascorbic acid treatment showed complete disappearance of the marrow and soft tissue oedema around the proximal tibia and fibula metaphyses. The joint effusion had also disappeared. The minimal residual changes were subtle thickening around the proximal fibula and some minor narrowing of the lateral tibia growth plate.
Scurvy is usually a clinical diagnosis caused by vitamin C deficiency which is common in developing countries and often seen in developed countries where there is a history of an eating disorder.
Joint pains are often seen but rarely imaged when the history is not in doubt. The bleeding gums are the best clinical evidence to the diagnosis. However if history is confusing, knowledge of the differential diagnosis of the imaging findings is required.
Osteomyelitis is most common. Haematological neoplasia, Henoch Schonlein, sickle cell disease, vitamin deficiencies such as copper deficiency, rickets, arthritis, syphilis and Non-Accidental Injury (NAI) should be considered in the differential diagnosis. [1]
On detailed history taking after the first MRI, there was no history of trauma or infection in this patient. Biochemical markers of infection were normal and there was no convincing evidence of haematological disease. NAI was not suspected. A clinical diagnosis of scurvy was made with unfortunately no evidence of biochemical vitamin C levels.
The MRI changes of scurvy which have been described only a few times show areas of sub-periosteal fluid and epiphysis displacement. The marrow appearances probably represent small areas of haemorrhage or small infarcts. [2]
Historically X-rays were performed in well-established cases of scurvy. These have shown changes of osteopenia with sclerotic thick metaphyseal lines above a widened physis and small beak-like excrescences. [3] In our case the X-ray was performed after a short duration of symptoms and was therefore unremarkable.
The bleeding gums and knee pain stopped shortly after ascorbic acid treatment. The patient was discharged after gaining 3 kg with intensive community-based care / dietary input.
The MRIs in an interval of 2 weeks show how easily and quickly the highly visible changes can be reversed if the correct clinical diagnosis is made quickly.
Scurvy
Based on the provided X-ray and MRI images of the right knee, the following key features were observed:
1. X-ray: The X-ray findings are relatively subtle, with no clear fracture lines or significant bone destruction, and no obvious proliferative or destructive lesions. Upon careful inspection, there may be a slight decrease in bone density around the metaphysis, but the overall image is not definitive.
2. MRI: On T1- and T2-weighted images and fat-suppression sequences of the right knee, there appears to be subperiosteal fluid signal (possibly mild hemorrhage or exudation) in a superficial or band-like pattern near the metaphysis; parts of the bone marrow show an uneven signal change, suggesting the possibility of minor marrow edema and hemorrhage. Slight irregularities can be noted near the growth plate, possibly reflecting changes due to vitamin deficiency.
In addition, the patient exhibits gingival bleeding (clinical photographs show gum recession and localized bleeding). Considering the overall clinical history (eating disorder, low body weight, iron-deficiency anemia), a deficiency of vitamin C should be highly suspected.
Combining the patient’s underlying medical history and imaging findings, the following potential or differential diagnoses should be considered:
Considering the clinical presentation (long-term eating disorder, body weight below the 0.4th percentile, gingival bleeding, joint pain), laboratory findings (iron-deficiency anemia), and the subperiosteal exudate-like changes on MRI, the most likely diagnosis is:
Scurvy (Vitamin C deficiency).
Bone and soft tissue pathological changes caused by vitamin C deficiency can rapidly reverse after vitamin C supplementation. The patient’s joint pain significantly improved within 3 days and normal walking function was restored, further supporting this diagnosis.
Treatment Strategy:
1. Vitamin C supplementation: Oral or intravenous vitamin C at appropriate dosages, with adjustment based on serum vitamin C levels and clinical response.
2. Nutritional support: To correct the patient’s eating disorder and malnutrition, a multidisciplinary team (nutrition, psychology, pediatrics, etc.) should collaborate to develop an individualized dietary plan ensuring sufficient intake of energy, protein, and other micronutrients (e.g., iron, calcium, vitamin D).
3. Psychological/psychiatric intervention: For patients with an eating disorder, appropriate psychological counseling or psychiatric medication should be considered to reduce the risk of relapse.
4. Symptomatic treatment: If pain is significant, short-term use of safe-dose analgesics may be considered while adequately supplementing vitamin C; closely monitor skeletal and hematological parameters.
Rehabilitation/Exercise Prescription:
After acute symptoms have subsided, help the patient gradually regain physical fitness and joint function, following the principle of safety and progressive increments:
1. Early Stage (Week 1-2):
Special Precautions: Throughout the rehabilitation process, closely monitor the patient’s nutritional status and changes in knee pain. If marked discomfort or worsening pain occurs, promptly stop the related exercises and seek medical evaluation.
This report is based on the analysis of the currently provided images and clinical information, without cross-verification against the complete medical record or other test results. It has certain limitations. The above diagnosis and treatment suggestions are for clinical reference only and cannot replace in-person diagnosis or professional medical advice. If there are any questions or changes in the patient’s condition, please consult a specialist doctor or visit a hospital promptly.
Scurvy
